Paying for organs

We have recently seen the idea of buying/selling/trading organs thrust into the media spotlight (and not for the first time). There’s a lot of very poor thinking floating around in this debate, though Sue Rabbitt Roff’s recent paper, which helped fuel the flames of the new debate, is a little more useful.

A market for organs?

There are many reasons why Sue Rabbitt Roff does not propose this, and why Iran is the only country that has adopted one. Ethically the practice is, at best, dubious. At worst it is massively exploitative. Without enough regulation and administration to render it pointless, a market would be hugely inequitable and contradictory to most Western government policy; it would redistribute health from the poor to the rich. However, as heartless machines of rationality, economists tend to be more interested in what is the most efficient policy to adopt. Economists (such as Becker and Elias) have been weighing-in on this issue for a while. In their enjoyable free-marketeer rantings on the topic, the folks at Freakonomics seemingly raised ‘repugnance’ as the only argument against a market for organs. But hopefully readers of this blog are a little more informed when it comes to health economics and realise that a market for organs, like any free market healthcare system, will be massively inefficient. Market-failures (both the “this market doesn’t look how we want it to look” kind, as well as actual market failure) would abound. While the rich’s willingness to pay for organs would far exceed that of the poor, most of us would accept that their capacity to benefit from organ donation would be the same (or lower) than that of the poor. Because the rich assign a higher monetary value to their health it would be possible for there to be a net loss of health from the purchase of an organ. In a free market system organs would, presumably, go to those who can afford them (the rich), rather than those who stand to gain the most from receiving them (the sick). And we all know that the richest are rarely the sickest. To me, none of this sounds very efficient.

Another way?

In the UK the idea of a free market for health care is repugnant enough; thankfully there is little chance of a market for organs developing. However, Sue Rabbitt Roff’s paper does not suggest this. This BMJ article doesn’t really say much and is quite limited. Economists should be chomping at the bit with claims like:

“…if the standard payment [for a kidney] were equivalent to the average annual income in the UK, currently about £28000, it would be an incentive across most income levels for those who wanted to do a kind deed and make enough money to, for instance, pay off university loans.”

Rubbish. But that doesn’t matter. Her general idea – a heavily-regulated system of organ purchase by the NHS -is a feasible one. Let’s remember that here we are talking about anonymous donors and recipients – family and friend donations could remain as they are. To be equitable there could be a fixed payment from the NHS to a donor. The level of this payment should be equal to (society’s valuation of) the health gain enjoyed by the individual receiving the transplant. In a world of value-based pricing this would be the norm! A second requirement would be that the price should be greater than or equal to the loss of health-related quality of life (plus other associated costs) to the donor. This would mean that a donation could be prevented if deemed exploitative, even if against the wishes of the donor. Such a system could nicely boost the supply of organs to existing (need-based) waiting lists.

This will probably be piloted in Scotland: the land of new ideas. For me a system would have to be so heavily regulated that there would not be much point. Politicians, clinicians and academics would love a quick-fix for the problem of organ shortages, but they’ll just have to work a bit harder. People can be encouraged to donate organs in other ways; a switch from opt-in to opt-out posthumous donation being an excellent start.

What do you think? Could the sale and purchase of organs be efficient and equitable? What safeguards would need to be in place if a system was introduced?

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